Direct Deposit Enrollment/Change Form Company Name____________________________________ Client Number____________________ Employee/Worker Name_____________________________ Employee/Worker Number__________ EMPLOYEE/WORKER: Retain a copy of this form for your records. Return the original to your employer. EMPLOYERS: Return this form to your local Paychex office. For clients using on-line services, please retain a copy of this document for your records. COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY Type of Account

Routing/Transit Number

Checking/Savings Account Number*

Financial Institution (“Bank”) Name

I wish to deposit (check one):

 Checking  Savings

 _____ % of Net  Specific Dollar Amount $ _______________.00  Remainder of Net Pay

 Checking  Savings

 _____ % of Net  Specific Dollar Amount $ _____________________________ .00  Remainder of Net Pay

COMPLETE IF CHANGING EXISTING DEPOSIT AMOUNTS – PLEASE PRINT IN BLACK/BLUE INK ONLY Routing/Transit Number

Checking/Savings Account Number*

Financial Institution (“Bank”) Name

Change My Deposit Amount to:  From _____% to____% of Net  From $ ______ .00 To $_____.00  Remainder of Net Pay  From _____% to____% of Net  From $ ______ .00 To $_____.00  Remainder of Net Pay

EMPLOYEE/WORKER CONFIRMATION STATEMENT

PLEASE SIGN IN BLACK/BLUE INK ONLY I authorize my employer to deposit my wages/salary into the bank accounts specified above and, if necessary, to electronically debit my account to correct erroneous credits. I certify my account(s) allow these transactions. I agree that direct deposit transactions I authorize comply with all applicable laws. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named account. Employee/Worker Signature ______________________________________ Date ________________

Note:

Digital or Electronic Signatures are not acceptable.

One of the following is required to process this enrollment (check one):  Voided check with name imprinted (no starter checks)  Deposit slip (only accepted if the verbiage “ACH R/T” appears before the routing number)  Bank letter or specification sheet (the signature of your local bank representative MUST be included) 

Other Bank Documentation from your Financial Institution – If this box is checked the employer must sign this confirmation: I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by Paychex, Inc.

Employer Printed Name:________________________________ Employer Signature:_____________________________________

Date _______________

*Certain accounts may have restrictions on deposits and withdrawals. Check with your bank for more information specific to your account.

DP0002 7/16 Form Expires 7/30/19